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WORKER'S I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
dr n certificate of-Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
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cy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING /
ADDRESS
department. (PRINT OR TYPE ONLY) L!/
Date Applicant l
LOCALITY �'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1—
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCES D BY
• I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU o�
become subject to the Workers' Compensation Laws.
Date.;/— /' C / A Ick � !v2 COMPRESSOR,BTU O�
APPROVALS DATE INSPECTOR'S SIGNATURE
Pfjl� VENTILATION SYSTEM --
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL IL_54Z�
provisions or this permit shall be deemed revoked. FURNACE: FAUG AVITY J VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU e9,00 v /
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Num bLic.Class
Contract o Date O
❑ Plan check fee D 0 Q
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$ i3 D"0 O
Date: TOTAL FEE w
Signature' a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
Z
I hereby affirm that I am exempt from the Contractor's License Law NAME '
for the following reason (Section 7031.5, Business and Professions
Code): F +- •I
ADDRESS
El
I, as°owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. 3307 6
structure is not intended or offered for sale (Section 7044, J. I EMS
Business and Professions Code). OWNER
❑ 0
I, as owner of the property, am exclusively contracting MAIL t f:e �
with licensed contractors to construct the project (Sec- ADDRESS +HE K
tion 7044, Business and Professions Code). 01
H
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 4_.fitii4tJE �J
hereby affirm that there is a construction lending agency for
€
I CONTRACTOR ,
I performance of the work for which this permit Is issued G
(Sec.3097, Civ. C.).
ADDRESS 61
';i' •'
i
Lender's Name a
CITY EL.NO.I X �O�� _n t Ar
Lender's Address LIC
,� . V /'
I certify that I have read this application and state that the above LICENSE NO �j CLASS C v
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
prope for inspection purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SlIGNATURE OF APPLICANT OR AGENT DATE